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Metastatic hormone-sensitive prostate cancer with imminent spinal cord compromise — MSRA MCQ

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HardProstate CancerMetastatic hormone-sensitive prostate cancer with imminent spinal cord compromiseMSRA

A 71-year-old man has newly diagnosed metastatic hormone-sensitive prostate adenocarcinoma (PSA 184 micrograms/L; biopsy Gleason 4+5=9). Staging CT shows pelvic nodal and extensive vertebral metastases. Following new thoracic pain, whole-spine MRI shows a T7 vertebral metastasis with posterior epidural extension and marked canal narrowing. He has normal power, sensation, gait and sphincter function. After urgent spinal oncology review, there is no current indication for decompression or immediate radiotherapy, but the MDT considers progression-related cord compromise a substantial risk and plans to start androgen deprivation therapy today. He wishes to avoid surgery if an equally effective medical option is available. Which initial androgen-deprivation regimen is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Start a GnRH antagonist (degarelix) as initial androgen-deprivation therapy

Explanation lettering: C = shown as A · E = shown as B · A = shown as C · B = shown as D · D = shown as E

A GnRH antagonist is the best initial medical androgen-deprivation therapy because this man has non-castrate metastatic prostate cancer with actual or imminent risk of spinal cord compromise. GnRH antagonists avoid the initial luteinising hormone and testosterone surge associated with GnRH agonists, so avoid tumour flare at a site where even short-lived progression could cause neurological injury. NHS Scotland cancer guidance specifically identifies actual or imminent spinal cord compression as a circumstance in which an antagonist such as degarelix should be considered. B is a credible usual approach: a GnRH agonist with bicalutamide flare protection is commonly used for metastatic disease. However, where tumour flare would be especially hazardous, an antagonist is preferred. C exposes him to unmitigated flare and is inappropriate. D is reserved for selected people willing to accept reduced overall survival and gynaecomastia in an attempt to retain sexual function; that is not his priority or clinical context. E provides effective immediate androgen deprivation without flare and remains an alternative for metastatic disease, but he has explicitly declined surgery where an equally effective medical option is available.

Reference: NHS Scotland Cancer Collaborative Clinical Management Pathway: Androgen Deprivation Therapy (Accessed 15 August 2026) — https://www.rightdecisions.scot.nhs.uk/nhs-scotland-cancer-collaborative-clinical-management-pathways/prostate-cancer/systemic-anti-cancer-therapy-sact/androgen-deprivation-therapy/ Degarelix Ferring 80 mg powder and solvent for solution for injection: Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/100905/smpc Staladex 11.25 mg implant: Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/15547/smpc